The above-named patient (or guarantor) agrees to make monthly payments on the balance of this account. Payments will be made on or before the
Failure to meet this obligation will make the agreement null and void and the practice will then reserve the right to forwarded to a collection agency for extended payments.
Minimum monthly payment agreed upon:
ALL FURTHER CHARGES WILL BE PAID AT THE TIME OF SERVICE.
In order to accomplish our payment plans in a cost-effective manner for all our patients, we ask that you adhere to our practices financial policy. By signing below, you are agreeing to its terms:
1. I am ultimately responsible for payment of charges for services I receive from this practice including those covered by my insurance. As a convenience, this practice will submit claims for reimbursement with my insurance provider; however, all payment responsibility is ultimately mine.
2. Some immediate payment may be expected at the time of service. Including a co-pay and/or additional payment, if the practice determines that the cost of my visit today will not be reimbursed by my insurance provider.
3. HWHC may deny service or charge a service fee for failure to pay a copay at the time of service.
4. It is my responsibility to provide my current address, telephone number, email address, and insurance information at each visit.
5. I agree to provide HWHC with my debit/credit card or ACH information.
6. I understand that my signature and payment information will be maintained on file digitally for future use by HWHC. The applicable payment card or bank information will be truncated and “tokenized” in order to help maintain the security of my payment information. Card or bank information will be obtained through a card swipe, manual entry from card, voided check, or orally in person or over the phone.
7. I authorize HWHC to apply charges to my payment card and/or bank account for all amounts owed to the practice for medical visits, procedures or supplies, including amounts agreed as part of a payment plan, copayments, coinsurance (after application of insurance proceeds), and amounts not covered by insurance.
8. In the case of a patient balance that is not satisfied by a charge to my payment method or a payment plan, I may receive a monthly statement for any outstanding balance. I am responsible for paying this balance by its due date in order to avoid paying possible interest on the balance.
9. Transaction receipts will be maintained in the patient file or will be emailed to me if I provide and maintain a valid email address.
10. I authorize HWHC to send electronic account statements and invoices to my email address on file. I understand that it is my responsibility to maintain a current email address on file and that I may not receive a mailed copy of any electronic statement.
This authorization will remain in effect until I provide written notice of cancellation to the practice. Authorization for services already rendered cannot be cancelled or refunded. I agree to notify the practice in writing of any changes in my payment or other information.
An original copy of this agreement must be provided to the patient and a copy of this agreement must be place in the chart in e-MDs.
By clicking Submit you agree the above information is correct and agree that all signatures are E-Signatures.